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MONITORING SYSTEM CERTIFICATION NOV 2 1 2011 For Use By.411 Jurisdictions Within the State of California Authority Cited. Chapter 6.7, Health and Safety Code: Chapter 16, Division 3, Title 23, CaffK PA Xe'MEALT H This form must be used to document testing and servicing. of monitoring equipment. A separate certification or repMFt IVI N:5WTor each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Arco Bldg.No.: Site Address: 1340 Colony Rd _ City: Ripon,Ca. Zip: 95366 Facility Contact Person: Ranjeet Contact Phone No.: (209) 5791€014 Make/Model of Monitoring System: Veeder Root TLS-350 Date of Testing/Servicing: 10124120/7 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment inspected/serviced: Tank ID: T1: 87 Tank ID: T2: 91 ®In-Tank Gauging Probe. Model 846390-111 ❑In-Tank Gauging Probe. Model: 845390-111 13 Annular Space or Vault Sensor. Model: 794380-303 l Annular Space or Vault Sensor. Model: 794380-303(split tank) 0 Piping Sump t Trench Sensor(s). Model: 794380-2081794380-304 ®Piping Sump/Trench Senson(s). Model: 794380-2081794380-304 ®Fill Sump Sensor(s). Model: 794380-208 1794380-304 Fill Sump Sensor(s). Model: 794380-208 1 7943 80-304 ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector- Model: ®Electronic Line Leak Detector. Model: 8484 M Electronic Line Leak Detector. Model: 8484 ❑Tank Overfill I High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Tank ID: T3: Diesel Tank ID: Z In-Tank Gauging Probc. Model: 846390-111 ❑ In-Tank Gauging Probe- Model: Z Annular Space or Vault Sensor, Model: 794380-303(split tank) ❑Annular Space or Vault Sensor. Model: iii Piping Sump/Trench Sensor(s). Model: 794380-2081794380-304 ❑Piping Sump/Trench Sensor(s). Model: ❑Fill Sump Sensor(s). Model: 794380-208 1794380-304 ❑Fill Sump Sensor(s). Model: ❑Mechanical Line Leak Detector. Model: ❑Mechanical Line Leak Detector. Model: ®Electronic Line Leak Detector. Model: 8484 ❑Electronic Line Leak Detector. Model: ❑Tank Overfill I High-Level Sensor. Model: ❑Tank Overfill/High-Level Sensor. Model: ❑Other(specify equipment type and model in Section E on Page 2). ❑Other(specify equipment type and model in Section E on Page 2). Dispenser ID: 1&2 Dispenser[D: 3&4 ®Dispenser Containment Sensor(s). Model: 794380-2081794380-304 ®Dispenser Containment Senson(s). Model: 794380-2081794380-304 Shear Valve(s). ®Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 5&6 Dispenser ID: 7&8 ®Dispenser Containment Sensor(s). Model: 794380-208 1794380-304 ®Dispenser Containment Sensor(s). Model: 794380-208 1794380-304 ®Shear Valve(s). Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s). Dispenser ID: 9&10 ; 11&12 Dispenser ID: 13&14 ; 15&16 ❑ Dispenser Containment Sensor(s). Model: 794380-208 1794380-304 ❑Dispenser Containment Sensor(s). Model: 794380-208 1794380-304 Z Shear Valve( Shear Valve(s). ❑Dispenser Containment Float(s)and Chain(s). ❑Dispenser Containment Float(s)and Chain(s)- *If the facility contains more tanks or dispensers,copy this form. Include information for every tank and dispenser at the facility. C. Certification -1 certify that the equipment identified in this document was inspectedlserviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, 1 have also attached a copy of the report;(check all that apply): System set-up ® Alarm history report Technician Name{print}: Guadalupe Sanchez Signatures<< 10,11-1 Certification No.: A30138 License.No.: 1005444 Testing Company Name: Diamond Petroleum Services, Inc. Phone No.:(925) 470-0803 Testing Company Address: 3619 King Ct.Antioch, CA. 94509 Date of Testing/Servicing: 1012412017 Page 1 of 4 Rev(2/08)